<p> Parental Refund Authorization Form Federal Direct Plus Loan</p><p>TO: Bethune-Cookman University (Office of the Bursar)</p><p>Student’s Name: ______</p><p>Student I.D. #: ______</p><p>Please Check One:</p><p>_____ Full (100%) Refund to Student The undersigned hereby requests and authorizes the entire credit balance on the account of ______be refunded to him/her. Student’s Name </p><p>_____ Partial Refund to Student The undersigned hereby requests and authorizes the amount of $______on the account of ______be refunded to him/her and $______Student’s Name be mailed to me at:</p><p>Name: ______</p><p>Address: ______</p><p>______</p><p>_____ No Refund to Student The undersigned hereby requests that no portion of the credit balance due to me from the account of ______be issued to him/her. Please mail full amount to me at: Student’s Name</p><p>Name: ______</p><p>Address: ______</p><p>______</p><p>Parent/Guardian Signature: ______Date: ______</p><p>STATE OF: COUNTY OF:</p><p>On ______before me, ______, (Date) (Notary) personally appeared ______, personally known to me (or proven to (Parent/guardian’s name) me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are in his/her/their authorized behalf of which the person(s) acts, executed the instrument.</p><p>WITNESS my hand and official seal.</p><p>Signature ______(Seal) Affidavit ______Known______Unknown______</p><p>ID Produced______Parental Refund Authorization Form Federal Direct Plus Loan</p><p>This Parental Refund Authorization Form (see reverse side) is designed for students who</p><p> are requesting refunds to be issued in the student’s name when the parent or guardian</p><p> signed for a Federal Direct Plus Loan.</p><p>If the Parental Refund Authorization Form is Not completed, the refund will automatically be issued to the</p><p> parent or guardian who signed for the loan.</p><p>This form must be Signed & Notarized and returned to:</p><p>Bethune-Cookman University Office of the Bursar Attn: (Your Staff Accountant’s Name) 640 Dr. Mary McLeod Bethune Boulevard Daytona Beach, FL 32114-3099</p><p>The form may also be faxed to the Bursar’s Office at 386-481-2512.</p><p>Please Note: If the parent or guardian signs this form and checks Full Refund or Partial Refund, </p><p> the parent or guardian is</p><p> authorizing the Office of the Bursar to issue a refund in the student’s name.</p><p>This Form is valid for only one (1) academic year and must be renewed for the following academic year.</p><p>Staff Accountants</p><p>If you have any questions concerning this form, please call your Staff Accountant.</p><p>Mrs. Pratima Mewar Ms. Jennifer Adjetey 386-481- 2032 386-481-2516 (A – I) (J – R) Ms. Mose 386-481-2535 (S-Z)</p>